Theoretical epidemiologists along with clinical specialists are currently occupying top medical posts in the centre as well as states. This has only worsened the situation as they have very poor knowledge of working in a field situation.
By Dr Suresh Singh
We are facing what could be easily termed as the biggest crisis of this century. Yet sadly, some Indian medical experts are either ignorant or seem to have forgotten the basic principle of fighting a communicable disease. With more than 220 epidemiologist posts throughout India lying vacant presently, districts could not be guided properly. Theoretical epidemiologists along with clinical specialists are currently occupying top medical posts in the centre as well as states. This has only worsened the situation as they have very poor knowledge of working in a field situation. Little surprise, we see a confused strategy in the fight against COVID19 with the peace-meal implementation of basic principle in the fight against Corona. In fact, it would not be wrong to say that the strategy has not been clear from the very beginning.
The basic strategy?
Since independence, India’s fight against the infectious disease has had three basic principles:
Case finding by the house to house survey and lab testing; Treat accordingly; and preventive measures. These basic principles are followed in all our National Health Programmes e.g. Malaria, Leprosy, TB, Immunisation Programmes, etc. Though modification is done here and there, the basic principle remains.
How to apply it Coronavirus?
Case finding: once a positive case is detected, house to house survey and lab tests should be done in the whole area. This principle can be applied even in a single positive case.
Treatment: Patients should be treated in designated quarantine centres for mild cases, and in hospitals for severe cases. Because of the disease’s highly infectious nature, nobody can be treated at home.
Preventive measures: Shutdown is the best method because of dangerous infectious nature of the disease. The first wave of the shutdown was our PM’s masterstroke, the best and timely. The 2nd and 3rd wave of the shutdown, however, was unnecessary as 14 day period is the standard incubation period accepted world-wide. Though some studies did mention it as 1-3months etc., I would call it an exception rather than a general rule.. Use of Mask of any kind by everybody in hospitals & crowded areas is critical. This is 2-way traffic- not only corona but other URTIs to keep self and another person safe; keeping a physical distance of 6 feet head to headcount and frequent hand washing and other hygienic conditions, etc.
Can we do house to house survey and testing? Of course, we can, we have the manpower and resources. For every 5000 people in rural /urban areas, we have 4/5 health workers doing the same work. Those are ANMs, Male Health Workers, 4/5 Anganwadi/ASHA workers. And this can be supplemented by giving them one-week basic training with basic materials needed with help from community leaders/NGOs.
Is it implemented? Certainly not. Delhi and Maharashtra have done so but it was late i.e. from around 15th April or so. But this is piece-meal implementation, not to the full extent. Once Dharavi, Asia’s largest slum with 10 lakh population, got infected on April 1, the whole slum should have been quarantined strictly with no movement allowed. With the physical condition of 4/5 persons in a crammed 3-room, open drainage, common toilet, etc., complete quarantine is a necessity. The same is true of Delhi. With 14-day mandatory quarantine not enforced strictly, it gives birth to the possibility of future positive cases. Sadly, several states are doing the same patchy work.
Are we to extend again for 4th wave, 5th wave and so on? What is the basis for it, when to stop and not to stop? Are we to continue for 1yr extension or so, can the nation afford it?
These are the pertinent questions one has to ask and be answered by those responsible. Similarly, red, yellow and green zones are unclear and have led to confusion. We should have positive red and negative white zones only. Even if one positive case is found, be it in the red zone, there should be no discrimination between the small and big number of cases. This should be followed up by house to house survey and testing and total 14-day shutdown. Area and zone of containment should be left to the local administration based on the geographical condition of the area. Another survey and testing may be done a week later and the same steps need to be followed. Presently, survey and testing are not covering the whole population of red zones, remnants of positive cases go on spreading the disease uninterrupted. This is exactly what is happening now.
Community transmission and testing: On 22nd March, I had written on the PMO website that with 64 in Maharashtra, 49 in Kerala and 26 in Delhi, of India’s 324 nos., community transmission with contact transmission is taking place. It was mentioned that we are in the early 3rd stage of Community transmission along with the 2nd stage of contact transmission.
With 324 positive cases spreading, further request to PM was to shield Maharashtra, Kerala and Delhi border immediately with specific area quarantine for 2 weeks. Another mention was special monitoring of UP, Karnataka and Rajasthan with border seal in case of abnormal increase in positive cases. Luckily, PM declared his masterstroke of 1st wave of shutdown for 21 days on March 24th itself. This has saved India from lakhs of positive cases.
Testing is very important as it helps in getting the real picture of the transmission and it will help in preventing community spread with more preventive measures in place.
With fewer tests, we help the virus to spread and spread more. This is exactly happening now. This is basically based on epidemiological triad. Any doctor with a common sense of epidemiology can understand it easily. Sadly it is lacking in present-day India’s top medical team. Our present medical team requires fine-tuning.
The virus has spread in over 414 out of 733 districts and ICMR is still denying community transmission – a strange phenomenon indeed.
More important is the daily number of new cases, 3,390 and more worrying is the new addition per day hovering around 2,000-4,000 per day in the last two weeks. And based on media reports, the numbers have gone up from 1.000 to 10,000 in 16 days and it jumped to 40,000 from 30,000 in 4 day and to 50,000 from 40,000 in 3 day.
A good sign is increased testing. Cumulative testing which was 66,000 on 3rd April is 1.44 million so far with 95,000 tests a day. Still, we require more testing which will give more positive cases. This will help us in containment measures and thereby prevent further community spread. Maharashtra with 17,974 positive cases and accounts for almost 32% of India’s total testing and has given more positive cases.
The uncontrolled situation is due to the patchy application of infectious disease control strategy with 14-day mandatory quarantine not enforced in all positive areas leading to spread of Corona to neighbouring areas. More death is due to a lack of good treatment care along with a severe form of Nizamuddin related cases. These should be the focus area, India should learn from this. As about 60% of India’s total cases are from 12 cities now, we should strategise more.
Ifs and Buts: If PM’s 1st wave of the shutdown was not implemented, India’s cases would have been in lakhs by this time. However, the hard-earned success was spoiled by uncontrolled border movements at Delhi in the early-stage. With community spread taking place mainly in urban areas, positive cases are bound to increase in coming days along with increased testing. With the present incomplete control strategy, one can see an increase and decrease pattern in the curve in the coming days and months. I will not be surprised if the number climbs to at least 1 lakh in the next month. We can expect around 2-3 lakhs in the next 6 months, even more without the basic strategy. The 2nd wave of infection and herd immunity-with community spread already there, the population has already developed the so-called natural herd immunity i.e. un-vaccinated community immune response to corona thus stopping its spread.
India’s Corona is a milder form and is likely to stay as such. Let Indian and others continue research to find the cause-BCG, Polio, Chicken Pox, Chloroquine intake etc.–the most plausible cause is the resilience of India’s population as they are exposed to many infectious diseases and have high natural immunity to fight the same. The same is seen in neighbouring Bangladesh, Pakistan, Sri Lanka, etc.
Conclusion: PM and his team have to go to the basic principle of fighting a communicable disease enumerated above. By doing so, we can slash down the number from lakhs to 1000s in the coming period. It may be pertinent again to emphasise that Pan-India shutdown is not required, no medical basis for it, only complete quarantine of the red area is needed including a single positive case area. Other areas may be freed but on a graded scale as is being done now. All economic activities may be opened fully without restrictions. Corona free North Eastern States also require a different shutdown strategy.
The author is Ex-Director, Health, Manipur, and MD & WHO Fellow. Views expressed are personal.)